Urban docs and country cousins

Family doctors just aren't what they used to be

Why city docs are office-bound, hospital-shy and offering
a narrower range of services than they used to

By Craig Silverman

A family doctor in the Toronto area and president of the Ontario College of Family Physicians, Dr Rachlis says he's spending less time working in the hospital and has cut back on activities such as surgical assisting.

"One of the changes that occurred in my practice in the last 10 years is that I stopped working in the emergency departments of hospitals," says Dr Rachlis.

The changing role of Canada's FPs has caused a bit of a stir lately thanks to the release of a report from the Canadian Institute for Health Information (CIHI) entitled The Evolving Role of Canada's Family Physicians: 1992-2001. The CIHI report reveals that significant change is afoot in family doctors' clinical areas of participation. On average, they are participating in fewer clinical areas, spending less time offering services in hospitals, and are offering more mental health services. It also found that urban physicians like Dr Rachlis tend to focus more on in-office areas and participate in less clinical areas overall.

MORE TIME IN THE OFFICE
The report examined data in nine clinical areas and noted relatively sharp drops in participation in four of them: surgical services (32% decline), surgical assistance (31%), anesthesia (28%) and obstetrical care (43%). The only area with an overall increase was mental health services, offered by 85% of physicians in 2001, up from 82% in 1992. "There are lots of family physicians doing extensive work in psychotherapy because there is an inadequate number of psychiatrists," explains Dr Rachlis.

The decline in participation in certain areas dovetails with a marked decline in hospital inpatient care. In 1992, 71% of physicians participated in hospital inpatient care. That number dropped to 62% by 2001. The average number of hospital visits by family physicians also declined by 8% over the same period. The report found that office assessment services make up approximately two-thirds of all services offered by family physicians.

This isn't necessarily a good thing — nor is it always by choice. Family physicians, says Dr Rachlis, are feeling overwhelmed by their in-office duties, and hospitals now desire emergency doctors with higher expertise and certifications.

THE RURAL EXPERIENCE
While Dr Rachlis represents the majority of family physicians — older, urban and with a reduced scope — Dr Joshua Tepper, one of the report's co-authors, is typical of an important minority, younger rural physicians. Dr Tepper, a family physician currently working in Kirkland Lake, northern Ontario as a hospitalist, certainly has a varied repertoire. He does duty in the emergency room, performs advanced procedures and makes house calls and nursing home visits.

Rural doctors tend to participate in more clinical areas, including surgical services, basic procedures, advanced procedures and anesthesia, whereas doctors in urban areas tend to focus more on in-office areas and participate in fewer clinical areas overall. Younger rural physicians like Dr Tepper are also more likely to offer a wider range of clinical services — though their volume is lower — compared to older physicians who practice in fewer areas and spend more time on what they practise.

"If we look at this report we have a choice to make," says Dr Tepper. "We can say we want family doctors to go back to what they were doing before, or say this is the new reality," he adds. "If it is the reality then we have to decide what that means for patients, medical schools and how many doctors we need."

Dr Tepper thinks the report has served its purpose in that it's highlighted an area with a wide impact on physician services and shows what doctors are actually up to in a very real sense. But the results took even the authors by surprise. "Smaller studies had suggested we would see a decline," he says. "But it was more pervasive than we thought it would be. The other big surprise was that although we saw fewer people involved in a number of areas, those who were involved were doing so at a higher level."

Next issue: NRM looks at a relatively new doctor role — the hospitalist — with a full interview with Dr Tepper about his hospitalist experience.